<div class="row">

    <div class="col-md-12">      		
    	
    	<div class="widget stacked ">
    		<div class="widget-header">
                <i class="icon-list"></i>
                <h3><?php echo isset($title_for_layout)?$title_for_layout:$this->l('Creation of a Patient'); ?></h3>
            </div> <!-- /.widget-header -->

            <div class="widget-content">
            	<form type="form" class="form" action="<?php echo site_url('Doctor/Patient/create/'); ?>" method="post">
            	<section id="tables">
                    <div class="page-header">
                        <h3><?php echo $title; ?></h3>
                    </div>
	            	<div class="col-md-4">
						<div class="field<?php echo (form_error('firstname'))?' error':''; ?>">
							<label for="firstname"><?php echo $this->l('First name:'); ?></label>
							<input type="text" id="firstname" name="firstname" 
				                   value="<?php echo set_value('firstname'); ?>" 
				                   placeholder="<?php echo $this->l('Enter patient first name'); ?>" class="form-control" />
				             
				             <?php echo form_error('firstname', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
						
						<div class="field<?php echo (form_error('lastname'))?' error':''; ?>">
							<label for="lastname"><?php echo $this->l('Last name:'); ?></label>	
							<input type="text" id="lastname" name="lastname" 
				                   value="<?php echo set_value('lastname'); ?>" 
				                   placeholder="<?php echo $this->l('Enter patient last name'); ?>" class="form-control" />
				             
				             <?php echo form_error('lastname', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
						
						
						<div class="field<?php echo (form_error('email'))?' error':''; ?>">
							<label for="email"><?php echo $this->l('Email Address:'); ?></label>
							<input type="text" id="email" name="email" 
				                   value="<?php echo set_value('email'); ?>" 
				                   placeholder="<?php echo $this->l('Enter patient email'); ?>" class="form-control email-field"/>
				             
				             <?php echo form_error('email', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
						
						<div class="field<?php echo (form_error('username'))?' error':''; ?>">
							<label for="username"><?php echo $this->l('Username:'); ?></label>
							<input type="text" id="username" name="username" 
				                   value="<?php echo set_value('username'); ?>" 
				                   placeholder="<?php echo $this->l('Enter patient username'); ?>" class="form-control username-field"/>
				             
				             <?php echo form_error('username', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
						
					</div>
					<div class="col-md-8">
						<div class="field<?php echo (form_error('birthday'))?' error':''; ?>">
							<label for="birthday"><?php echo $this->l('Birthday:'); ?></label>
							<input type="date" id="birthday" name="birthday" 
				                   value="<?php echo set_value('birthday'); ?>" 
				                   placeholder="<?php echo $this->l('Enter your birthday date'); ?>" class="form-control datepicker" />
				             
				             <?php echo form_error('birthday', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
						
						<div class="field<?php echo (form_error('phone'))?' error':''; ?>">
							<label for="phone"><?php echo $this->l('Phone:'); ?></label>	
							<input type="text" id="phone" name="phone" 
				                   value="<?php echo set_value('phone'); ?>" 
				                   placeholder="<?php echo $this->l('Enter your phone number'); ?>" class="form-control" />
				             
				             <?php echo form_error('phone', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
						
						<div class="field<?php echo (form_error('profession'))?' error':''; ?>">
							<label for="profession"><?php echo $this->l('Profession:'); ?></label>	
							<input type="text" id="profession" name="profession" 
				                   value="<?php echo set_value('profession'); ?>" 
				                   placeholder="<?php echo $this->l('Enter your profession'); ?>" class="form-control" />
				             
				             <?php echo form_error('profession', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
						
						<div class="field<?php echo (form_error('pobox'))?' error':''; ?>">
							<label for="pobox"><?php echo $this->l('P.O.Box:'); ?></label>	
							<input type="text" id="pobox" name="pobox" 
				                   value="<?php echo set_value('pobox'); ?>" 
				                   placeholder="<?php echo $this->l('Enter your pobox'); ?>" class="form-control" />
				             
				             <?php echo form_error('pobox', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
						
						<div class="field<?php echo (form_error('town'))?' error':''; ?>">
							<label for="town"><?php echo $this->l('Town:'); ?></label>	
							<input type="text" id="town" name="town" 
				                   value="<?php echo set_value('town'); ?>" 
				                   placeholder="<?php echo $this->l('Enter your town'); ?>" class="form-control" />
				             
				             <?php echo form_error('town', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
						
						<div class="field<?php echo (form_error('nb_secur_social'))?' error':''; ?>">
							<label for="town"><?php echo $this->l('Social security number:'); ?></label>	
							<input type="text" id="nb_secur_social" name="nb_secur_social" 
				                   value="<?php echo set_value('nb_secur_social'); ?>" 
				                   placeholder="<?php echo $this->l('Enter your social security number'); ?>" class="form-control" />
				             
				             <?php echo form_error('nb_secur_social', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
						
								
						<div class="field<?php echo (form_error('address'))?' error':''; ?>">
							<label for="town"><?php echo $this->l('Address :'); ?></label>	
							<input type="text" id="address" name="address" 
				                   value="<?php echo set_value('address'); ?>" 
				                   placeholder="<?php echo $this->l('Enter your address'); ?>" class="form-control" />
				             
				             <?php echo form_error('address', '<span class="error">', '</span>'); ?>
						</div> <!-- /field -->
					</div>
				</section>	
				<div class="clearfix"></div>
				<div class="col-md-12">
					<div class="login-actions">		
						<button class="login-action btn btn-primary" name="btn_submit" type="submit" value="1"><?php echo $this->l('Create'); ?></button>
						<a class="login-action btn btn-danger" name="btn_discard" href="<?php echo site_url('Doctor/Patient'); ?>"><?php echo $this->l('Discard'); ?></a>
					</div> <!-- .actions -->
				</div>
			</form>
    		</div> <!-- /widget-content -->
    			
    	</div> <!-- /widget -->
    	
    </div> <!-- /span12 -->

</div> <!-- /row -->